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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
Safe Sleep

Introduction

This toolkit summarizes content from the Safe Sleep Evidence Accelerator and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.

From the MCH Block Grant Guidance. Sleep-related infant deaths, also called Sudden Unexpected Infant Deaths (SUID), account for the largest share of infant deaths after the first month of life.1 SUID includes Sudden Infant Death Syndrome (SIDS), ill- defined deaths, and accidental suffocation and strangulation in bed.

Due to heightened risk of SIDS when infants are placed to sleep in side (lateral) or stomach (prone) sleep positions, the American Academy of Pediatrics (AAP) has long recommended the back (supine) sleep position.

To further reduce SUID, the AAP has several other recommendations for a safe sleep environment that include using a firm non-inclined sleep surface (e.g., crib or bassinet), room-sharing without bed-sharing, and avoiding soft bedding and overheating.2

Goal. To increase the percent of infants placed to sleep on their backs and in a safe sleep environment.

Note. Access other related measures in this Population Domain through the Toolkits page.

Overview: Read a summary of the issue related to Title V

The following trends emerged from analysis of peer- reviewed evidence (Note: this review focused only on sleep position). These findings may serve as ideas to expand your ESM in the future.

  • Interventions targeting caregivers only appear to be somewhat effective.
  • Interventions implemented at the caregiver, health care provider, and hospital levels without quality improvement initiatives appear to be effective.
  • Interventions implemented at the caregiver, health care provider, and hospital levels with quality improvement appear to be somewhat effective.
  • National campaigns appear to be effective.
  • Due to the limited scope of included studies, there is less clear evidence of the effectiveness for interventions focusing on health care providers or child care providers only.1 

New Research!

Ashley HH, Kortsmit K, Kaplan L, Reiney E, et al. Prevalence and Factors Associated With Safe Infant Sleep Practices. Pediatrics November 2019, 144 (5) e20191286; DOI: https://doi.org/10.1542/peds.2019-1286. This article examines the prevalence of safe infant sleep practices and variation by sociodemographic, behavioral, and health care characteristics, including provider advice. It provides state-specific data on additional safe sleep practices that can help drive improvement. Findings relevant to Title V programs include:

  • Receiving provider advice was associated with increased use of safe sleep practices, supporting the importance of safe sleep promotion within health care settings. While more than 90% of women reported that a health care provider had told them to place their infant on their backs to sleep, only about half received advice to room-share without bed-sharing.
  • There is significant state variation in safe sleep practices, with estimates spanning 20 to 25 percentage points. These state differences were not explained by sociodemographic, behavioral or healthcare characteristics, which might instead reflect state or regional cultural norms or the influence of state-level educational campaigns to promote safe sleep practices.
  • "The findings from this study indicate that we need to redouble public awareness and provider training efforts on the safe sleep environment," said Lorena Kaplan, MPH, CHES of NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development. "Providers may need new resources like decision support tools and motivational interviewing to understand barriers and counsel parents more effectively."2 

Detail Sheet: Start with the MCH Block Grant Guidance

DEFINITION

Numerators:

A) Number of women who reported that they placed their infant to sleep only on their backs (not stomach or side) in the past two weeks
B) Number of women who reported that their infant always slept alone in their own crib or bed while they themselves were sleeping in the past two weeks. Cribs or beds include a crib, portable crib, or bassinet, and not a twin or larger mattress or bed, couch, sofa, armchair, car seat, swing, rocker, or other inclined sleeper.
C) Number of women who reported that their infant was not placed to sleep with comforters, quilts, blankets, non-fitted sheets, soft toys, cushions, pillows (including nursing pillows), or crib bumper pads (mesh or non-mesh) in the past two weeks
D) Number of women who reported that their infant’s crib or bed was in the same room where they or another adult slept in the past two weeks

Denominators:

A-D) Number of women with a recent live birth, excluding those whose infant has died or is not currently living with them

Units: 100

Text: Percent

HEALTHY PEOPLE 2030 OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 14: Increase the proportion of infants placed to sleep on their backs (Baseline: 78.7% of infants born in 2016; Target: 88.9%); Related to MICH Objective D3: Increase the proportion of infants who are put to sleep in a safe sleep environment. (Developmental)

DATA SOURCES

Pregnancy Risk Assessment Monitoring System (PRAMS)

MCH POPULATION DOMAIN

Perinatal/Infant Health

MEASURE DOMAIN

Health Behavior

Data Sources: Learn more about the issue and access the data directly

1. Accelerate with Evidence—Start with the Science

The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.

Evidence-based/Informed Strategies: MCHbest Database

The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.

Chart of Evidence-Linked Strategies and Tools

Evidence-Informed

Evidence-Based

Mixed Evidence

Emerging Evidence

Expert Opinion

Moderate Evidence

Scientifically Rigorous
 

 

Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub

Cutting Edge:

Emerging:

Promising:

Best:

Key Findings and Emerging Issues: Read more from the literature

KEY FINDINGS

  • Interventions targeting caregivers only appear to be somewhat effective.
  • Interventions implemented at the caregiver, health care provider, and hospital levels without quality improvement initiatives appear to be effective.
  • Interventions implemented at the caregiver, health care provider, and hospital levels with quality improvement appear to be somewhat effective.
  • National campaigns appear to be effective.
  • Due to the limited number of studies, there is less clear evidence of the effectiveness for interventions targeting health care providers or child care providers only.

IMPLICATIONS

  • Interventions implemented at the caregiver, health care provider, and hospital levels without quality improvement as well as national campaigns appear to be most effective in increasing exclusive supine sleep position in infants.
  • Future evaluations should assess the effectiveness of evidence-informed interventions by race/ethnicity as there is substantial variation in adherence to safe sleep recommendations among subgroups.
  • In addition to supine positioning, it is critical to adhere to additional safe sleep recommendations that were not examined in this review, including the use of a firm sleep surface, room-sharing without bedsharing, and avoidance of soft bedding and overheating.

EVIDENCE ANALYSIS REPORTS

Strategy Video: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches. Presented by Suzanne Bronheim, Georgetown University.

 

2. Think Upstream with Planning Tools—Lead with the Need

The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.

A. Move from Need to Strategy

Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.

Planning Tools: Use these tools to move from data to action

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Many of the strategies with the strongest evidence supporting them are those that are more clinical or those based in enabling services rather than those that can be easily implemented by Title V agencies. As we look to “move down the MCH Pyramid” with less emphasis on direct services (disease management) to an increased focus on public health services and systems (primary and secondary prevention and population health management), we are often challenged in identifying evidence-based/informed practices to meet the new focus of the transformed MCH Block Grant.1 

Where possible, we try to align evidence-based strategies (“what works”) to activities that can be adopted by Title V agencies (“what we can do”). However, there is often the need for adaptation and innovation.2 Sometimes it’s difficult to identify the role a Title V agency could take in implementing and/or adopting such evidence-based/informed strategies.

When deciding how best to implement a strategy that seems outside the typical role of Title V, it may be helpful to consider activities that support the strategy while aligning with activities that Title V is charged with,3 such as:

  • Assessing ongoing community needs: Title V can use data collected by programs, evaluations, or more formal needs assessment findings to see if the strategy could address identified service gaps or build equity in access and positive health outcomes.
  • Informing and educating the public: Title V can provide educational/outreach materials to families/consumers to advance the strategy through training and peer support.
  • Engaging community partners and families: Title V can serve as the convener for those groups/organizations that can implement the strategy.
  • Integrating systems of public health. Title V can help ensure access, sharing of resources, and coordination of services to assure maximum impact of the strategy (coordinating the public health approach, health care, and related community services).
  • Educating the MCH workforce (building capacity): Title V can partner with groups actually conducting this strategy in order to train MCH and healthcare professionals in strategy implementation.
  • Developing public health policies and plans: Title V can support adoption of the strategy at a state level.
  • Ensuring quality improvement and promoting applied research: Title V can collect data and evaluate programs in the state/jurisdiction that are implementing this strategy to build the evidence base and promote rapid innovation.

SDOH and Health Equity Considerations: Identify ways to advance health for all

Not all strategies are effective for all population groups, and the evidence is often lacking in terms of using specific strategies to advance health equity.

Once the evidence has been considered for what works generally,, it is important to understand if a specific strategy will work for targeted populations, especially those most affected by health disparities. Implementation science helps to translate the science into programs and policies that impact health outcomes in light of multiple social determinants. In finding strategies to meet needs, we have the ability to adopt and/or adapt what works.

ADOPT Strategies to Meet Needs

In choosing to adopt an existing strategy based on existing science and practice, we should consider:2

Is the study sample or population similar to our target audience?

  • ​Geography
  • Demographic characteristics
  • Culture, values, and preference
  • Health status
  • Other characteristics of interest 

Do we have the resources needed to implement?

  • ​Workforce capacity
  • Money
  • Time
  • Leadership 

Does our organization and the broader environment support the strategy? ​

  • Political support
  • Financial and legal support
  • Champions for intervention
  • Community norms and partnerships
  • Title V priority and jurisdiction
  • Favorable environment for change​​

Special Considerations: Tease out ways to zoom in on populations of focus

ADAPT Strategies to Meet Needs

Not all strategies are effective for all populations. To adapt strategies to meet needs, we should consider:5

What about the existing strategy works? If we understand the key ingredients of a strategy, we can replicate and/or adapt the effective components. Looking at a strategy through a health behavior theory identifies key ingredients. Here are several to consider:

How does it work? Being specific about the underlying mechanisms can help us increase the impact. Developing a logic model with program actions, targets, outcomes, and moderators allows you track the process from action to outcome.

For whom does it work, and for whom does it not work? When we know who is and is not responding, we can make targeted adaptations to improve outcomes. Think about the program life cycle:

  • Precision. Understand what a strategy entails so you can go beyond “does it work,” to “what about it works” and “for whom does it work.”
  • Fast-cycle iteration. Incorporate new ideas as you go – what is working and what is not working.
  • Shared learning. Create a mechanism to share learning about success and failures.
  • Co-creation. Bring together multiple parties to create a mutually valued outcome.

In what contexts does it work? By evaluating the context in which a strategy is implemented, we can adapt it for other settings. The best way to ensure that a strategy is effective is to conduct a robust evaluation. The MCH Navigator’s Evaluation Spotlight provides trainings and resources related to the steps and standards for effective program evaluation.

3. Work Together with Implementation Tools—Move from Planning to Practice

The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are movable within the realities of Title V programs and lead to health equity for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.

Additional MCH Evidence Center Resources: Access supplemental materials from the literature

Implementation Resources: Use these field-generated resources to affect change

References

Introductory References: From the MCH Block Grant Guidance

1 Moon RY, Carlin RF, Hand I; Task Force on Sudden Infant Death Syndrome and the Committee on Fetus And Newborn. Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths. Pediatrics. 2022;150(1):e2022057991.

2 Moon RY, Carlin RF, Hand I; Task Force on Sudden Infant Death Syndrome and the Committee on Fetus And Newborn. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022;150(1):e2022057990. doi:10.1542/peds.2022-057990. https://publications.aap.org/pediatrics/article/150/1/e2022057991/188305/Evidence-Base-for-2022-Updated- Recommendations-for

Overview References:

1 Lai Y, Garcia S, Strobino D, Grason H, Minkovitz C. National Performance Measure 5 Safe Sleep Evidence Review. Strengthen the Evidence Base for Maternal and Child Health Programs. Women’s and Children’s Health Policy Center, Johns Hopkins University, Baltimore, MD. 2017.

2  HRSA News Room. Study Finds Safe Infant Sleep Practices Need Improvement. HRSA 2019 Press Releases. October 21, 2019.

Toolkit References: From the Evidence Accelerator

1,3 Brownson RC, Fielding JE, Green LW. Building Capacity for Evidence-Based Public Health: Reconciling the Pulls of Practice and the Push of Research. Annual Review of Public Health 2018 39:1, 27-53.
2 US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Division of State and Community Health. Title V MCH Services Block Grant Guidance and Reporting Forms_10th Edition_December 2023 (hrsa.gov)
4,5 Adapted from IDEAS Impact Framework, Center on the Developing Child, Harvard University. 6Hayden J. Introduction to Health Behavior Theory, Second Edition. Burlington, MA: Jones & Bartlett Learning. 2014.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.